When do you intubate a burn patient?

I had a case a while back where we needed to intubate a patient with a significant burn to the upper chest and face. Due to his altered mental status, it was quite obvious that he needed to be intubated. Here is a clip of from our video laryngoscope showing soot / carbonaceous material in his airway.

I sometimes think about certain elements of intense critical cases for several days afterward. I found myself thinking after this case about the indications for intubation in a burn patient. Sometimes it is easy to know when to intubate, as in the patient above. Other times the decision is less obvious and we think hard through the pros and cons as well as the timing to intervene with a particular procedure. I find it interesting, but not surprising, that if you look at three different resources regarding when to intubate burn patients, you’ll find three different lists of criteria:

full-thickness burns of the face or perioral region

circumferential neck burns

acute respiratory distress

progressive hoarseness or air hunger

respiratory depression or altered mental status

supraglottic edema and inflammation on bronchoscopy-Tintinalli

Persistent cough, stridor, or wheezing

Hoarseness

Deep facial or circumferential neck burns

Nares with inflammation or singed hair

Carbonaceous sputum or burnt matter in the mouth or nose

Blistering or edema of the oropharynx

Depressed mental status, including evidence of drug or alcohol use

Respiratory distress

Hypoxia or hypercapnia

Elevated carbon monoxide and/or cyanide levels-UpToDate

Stridor is an immediate indication for intubation

‘Prophylactic’ intubation prior to transfer if history or signs indicate likelihood of inhalation and thus possible airway obstruction

Increasing swelling of head and neck

Unprotected airway

GCS<9

Uncooperative/combative/disoriented patient–Burn guidelines developed by The Alfred Hospital and Royal Children’s Hospital in Melbourne, Australia

Some of the bullets above are more obvious indications for intubation than others. Most EM clinicians would not intubate someone for (burn + singed nose hairs) or (burn + alcohol) or (burn + mildly elevated CO level). (I think UpToDate’s list is a little excessive). Most EM clinicians would intubate a burn patient with stridor, AMS, respiratory distress or unprotected airway. The important thing seems to be knowing to look for and recognize subtle and/or early indicators that the patient may have more trouble maintaining airway and ventilation in the near future.